NCG160172 DMR SW (7)

STORMWATER DISCHARGE OUTFALL. (SDO)-
GENERAL PERMIT NO. NCG160000
DISCHARGE MONITORING REPORT (DMR)
'C
CERTIFICATECOVERAGE No. NCG16❑�[]® SAMPLTS_COLLECTED DURING CALENDAR YEAR. -i EIVED
(This monitoring report is due at the Division no later than 30 days fro 412015
the facility receives the sampling results from the laboratory:)
RAL IDES —_
FACILITY NAMES COUNTY
D , c TION
PERSON COLLECTING SAMPLES 11 5 I l + PHONE NO. (7N_) 19,8 02-7.5
CERTIFIED LABORATORY 1 ff�l_
Lab #
Monitoring Requirements
Outfall Date 00530 00400
No. Sample Collected, Total Rainfall, I otal Suspended Solids, mg/l. ,` :.:: _ pH,
mo/dd/ r inches - ". ' Standard units
00556
Total Petroleum Hydrocarbons, mg/l,
EPA Method 1664 (SGT -HEM
Benchmark - - 100. Within 6.0 — 9.0
15
f/,SLGY)q N 1A
Nei
If a value is in excess of the benchmark, of outside the benchmark range (for pH), you must implement .the Tier I or Tier 2 responses in the General Permit.
Mail original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system; or'
those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate; and complete.
I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
L:�2�
(Signature of Permittee)
t g «
(Date)I—
S W t_I -25 2-05 1 409
Nage I of I